6/20/2018 PROCEDURAL TREATMENTS FOR HEADACHE. Case study: Emily. Diary

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1 Headache severity (Scale 0 10) Topiramate started on July 20, D/C July 29 Amitriptyline initiated, D/C on Sep 23 PROCEDURAL TREATMENTS FOR HEADACHE Andrew M. Blumenfeld Director of the Headache Center of Southern California IT/BTOX0252/17a Materiale ad esclusivo uso congressuale Data di preparazione Maggio 2017 Case study: Emily Patient History 43-year-old woman is seen for a main complaint of headache Has had headaches since her teens Reports near daily headaches Has migraine features: nausea, photophobia, and phonophobia Has tried multiple preventive medications Diary Triptan administered on 13 days 10 headache-free days 56 days with some level of headache W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W T F 66 Days 1

2 . The PREEMPT fixed-site fixed-dose injection paradigm A total of 31 injections across seven specific head and neck muscles, with a dose of 155 U of Ona-BoNTA (botulinum toxin type A) injected per patient Occipitalis (6 5 U) Temporalis (8 5 U) Frontalis (4 5 U) Procerus (1 5 U) Corrugator (2 5 U) Cervical paraspinal group (4 5 U) Adapted from Blumenfeld et al. Headache 2010;50: Trapezius (6 5 U) Ona-BoNTA: OnabotulinumtoxinA Types of ptosis Medial brow ptosis Brow ptosis Brow Lid ptosis Pseudoptosis The content of this slide was provided by Dr Blumenfeld 2

3 Supraorbital and supratrochlear nerves CSM, corrugator supercilii muscle; HL, horizontal intercanthal plane; SON, supraorbital nerves; STN, supratrochlear nerve; VL, vertical midline of the face. Anatomical injection sites follow distributions and areas innervated by the trigeminal sensory system Supraorbital nerve Supratrochlear nerve 1. Binder & Blitzer. Facial Plast Surg Clin N Am 2003;11: Blumenfeld et al. Headache 2010;50: Image adapted from Binder & Blitzer 2003 and Blumenfeld Corrugator injections 3

4 Procerus injections 4

5 Frontalis injections Occipitalis and cervical paraspinal muscles Occipital protuberance Nuchal lines Cervical paraspinal muscles Mastoid process 5

6 Greater and third occipital nerve Greater occipital nerve Lesser occipital nerve 3 rd occipital nerve Image adapted from Binder & Blitzer 2003 and Blumenfeld Adapted from: 1. Binder & Blitzer. Facial Plast Surg Clin N Am 2003;11: Blumenfeld et al. Headache 2010;50: Occipitalis injection sites The content of this slide was provided by Dr Blumenfeld Occipitalis injection sites 6

7 Cervical paraspinal injection sites. Cervical paraspinal muscles The content of this slide was provided by Dr Blumenfeld 7

8 The content of this slide was provided by Dr Blumenfeld Trapezius injections The content of this slide was provided by Dr Blumenfeld 8

9 Trapezius injection sites The content of this slide was provided by Dr Blumenfeld 9

10 Temporalis injection sites The content of this slide was provided by Dr Blumenfeld 10

11 Headache Severity (Scale 0 to 10) The auriculo-temporal nerve Auriculotemporal nerve Lesser occipital nerve Image adapted from Binder & Blitzer 2003 and Blumenfeld Binder & Blitzer. Facial Plast Surg Clin N Am. 2003;11: Blumenfeld et al. Headache 2010;50: First Ona-BoNTA injection cycle Triptan administered on 11 days 29 headache-free days 59 days with some level of headache F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F The content of this slide was provided by 88 Days Dr Blumenfeld. The PREEMPT modified follow-the-pain paradigm 1,2 Temporalis ( 2 5 U). Up to an additional two doses in either the right or left temporalis muscle, at the points of greatest pain 1,2 Occipitalis ( 2 5 U). Up to an additional two doses in either the right or left occipitalis muscle at the points of greatest pain 1,2 Trapezius ( 4 5 U). Up to an additional four doses in either the right or left trapezius muscle at the points of greatest pain 1,2 Total overall dose of up to 195 U of Ona-BoNTA 1,2 Figure adapted from Blumenfeld et al Blumenfeld et al. Headache 2010;50: Botulinum Toxin A, Summary of Product Characteristics 11

12 Targets Image provided by Dr Blumenfeld Sites to avoid, for safety Image provided by Dr Blumenfeld Clenching the jaw 12

13 Headache Severity (Scale 0 to 10) Headache Severity (Scale 0 to 10) Temporalis Fascia Covering Second Ona-BoNTA injection cycle Triptan administered on 4 days 58 headache-free days 27 days with some level of headache MTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SM The content of this slide was provided 85 by Days Dr Blumenfeld. Seventh Ona-BoNTA injection cycle Mar May Triptan administered on 2 days 68 headache-free days 14 days with some level of headache F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTW 13

14 Case study: Emily She has reduced her Botox treatment cycle to every 5-6 months. She has to take an examination and gets a breakthrough migraine unresponsive to home treatment. She comes in for nerve blocks and trigger point injections Greater and lesser occipital nerve blocks From Ashkenazi A, Levin M, Dodick DW. Peripheral procedures for headaches. In: Silberstein SD, Lipton RB, Dodick DW, eds. Wolff s Headache and Other Head Pain. Oxford University Press, 8th ed Occipital Nerve Blocks 14

15 Auriculotemporal nerve block From Ashkenazi A, Levin M, Dodick DW. Peripheral procedures for headaches. In: Silberstein SD, Lipton RB, Dodick DW, eds. Wolff s Headache and Other Head Pain. Oxford University Press, 8th ed Auriculotemporal nerve Supraorbital and supratrochlear nerve blocks From Ashkenazi A, Levin M, Dodick DW. Peripheral procedures for headaches. In Silberstein SD, Lipton RB, Dodick DW, eds. Wolff s Headache and Other Head Pain. Oxford University Press, 8th ed

16 Supraorbital and supratrochlear nerve blocks From Ashkenazi A, Levin M, Dodick DW. Peripheral procedures for headaches. In Silberstein SD, Lipton RB, Dodick DW, eds. Wolff s Headache and Other Head Pain. Oxford University Press, 8th ed Infraorbital nerve block Fixed Forward Head Posture 16

17 Trapezius Trigger Point Referral Pattern Sternocleidomastoid Trigger Point Referral Patterns Ptyergo-palatine gangliong Access above the middle turbinate Gravity used to target While the patient is laying supine, gravity will facilitate infused medication to collect and saturate the targeted area IF, the medication is dispersed over the top of the middle turbinate. 17

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